Trichotillomania

Trichotillomania is not a new disorder – rather it is “coming out of the closet” due to new treatments and recent publicity about the topic.

It was actually described as far back as the late 1800’s.

(There are even references to pulling out one’s hair in the Bible.) Until recently, trichotillomania did not receive much attention because it was thought to be so rare. The condition was described in psychology and psychiatry teaching programs as an oddity that one was unlikely ever to encounter in practice. Sufferers were as likely to seek help from dermatologists as psychiatrists in the recent past. Those seeking help often could not bring themselves to explain that they were causing their own hair loss, because of the shame of feeling “crazy” or out of control.

The prevalence of trichotillomania is unknown. It was considered to be rare until very recently because of the secretiveness of people suffering from the disorder who rarely sought help. Epidemiological studies so far indicate that the disorder is common, affecting as much as 2% of the population. Media attention often brings about thousands of requests for information about trichotillomania. Currently trichotillomania is officially classified as a disorder of impulse control, along the lines of pyromania, kleptomania, and pathologic gambling.

What are the symptoms?

There is virtually always some tension or urges associated with the disorder. Many describe the hair pulling as decreasing this tension. On the other hand, after an episode of hair pulling, the fear of losing control and becoming completely bald can cause an extreme heightening of their anxiety.

Many pullers have the habit of playing with the hair in some manner after pulling it out. They may touch the root to their lips or pull it through their mouth or hands. Many bite the root off and a few will eat the whole hair (called Trichophagia) which in rare cases has resulted in the need for surgical removal of the indigestible hair ball from the stomach.

Some describe pulling out hairs that “feel wrong” and many spend much of their time searching for the right hair to pull. Others select a “favourite” area of the scalp (or elsewhere) to pull from which may change in location over the years. Any area of hair growth such as the eyelashes, eyebrows, beard, chest hair, leg hair or pubic hair is a potential site for hair pulling.

The hair pulling is generally not painful. The number of hairs pulled during each episode may be a few, or a few dozen and may take from moments to hours. Most often hair pulling occurs while one is alone and during certain activities such as reading or watching TV. The preponderance of people requesting help for this disorder are women, although there is no proof that it is more common in women than men.

What treatments are available?

Because we don’t have a way of determining the cause in each case, the treatment is generally “empirical’, meaning that different treatments may need to be tried before finding the one that works. Since each trial may take several weeks or longer, patience is often required to achieve success in treatment.

Many people have grown up feeling they are the only ones who had this “strange” compulsion to pull hair and experience immense relief when they read or hear about it in magazines, newspapers, and television. This alone may help greatly in reducing the feelings of isolation and self-recriminations. It is also a relief to know there are potentially effective treatments for this condition.

The two methods of treatment that have been scientifically researched and found to be effective are behavioural therapy and medications. In behavioural therapy, patients learn a structured method of keeping track of the symptoms and associated behaviours, increasing awareness of pulling, substituting incompatible behaviours and several other techniques aimed at reversing the “habit” of hair pulling. For most, the addition of individualised behaviour analysis and treatment by a behavioural therapist experienced in treating trichotillomania is essential for effective treatment.

Advantages of behavioural therapy include the opportunity to be free of symptoms without potential side effects of medications. Relapses can be treated by the same methods. Disadvantages include a shortage of experienced therapists, the time commitment, and cost. It is probably the treatment of choice, although some may need reassurance that although they may believe they can never control their pulling and that the techniques sound similar to those they’ve tried on their own, behavioural treatment can be very effective.

Viewing trichotillomania as a medical illness rather than an uncontrollable habit may be beneficial in reducing self-derogatory feelings in hair pullers, but is not inconsistent with the efficacy of behavioural treatment. In OCD studies, behavioural treatment has actually been shown to change the biological functioning of the brain.

Medications have received the most research attention recently. Although medications clearly help some people at least temporarily, the few carefully controlled studies have been disappointing and lack long-term follow-up to determine how effective medications are in the long run. Symptoms are likely to return when stopping the medication unless one also uses behavioural techniques. The advantages of medications include ease of treatment, reduction of depression or obsessive-compulsive symptoms if present, and the compatibility with the idea that the illness is a medical one. The disadvantages include limited effectiveness for most, possible side effects and theoretical risks of long-term medication treatment. Worsening of symptoms may also occur with medication treatment.